LEADERSHIP & MANAGEMENT – the night, attempt to get up unassisted in

ASSIGNMENT/DELEGATION unfamiliar surroundings, and fall. Client

orientation and teaching are the
SCOPE OF PRACTICE responsibilities of the RN and are not
appropriate to delegate to the UAP.
• Alterations in gait, balance, and range of
motion places the client at a higher risk for
falling. Evaluating the client for gait and
balance deficits requires assessment and is
a function of the registered nurse. The
UAP may assist the client in ambulating
with assistive devices, but evaluating and
educating are not delegated.
• Unlicensed assistive personnel (UAP)
may assist stable clients with activities of
daily living, hygiene needs, ambulation,
and turning and repositioning. UAP may
also collect and record vital signs (eg,
pulse oximetry); obtain and set up
equipment; and take precautions to
UNLICENSED ASSISTIVE PERSONNEL prevent aspiration (eg, oral care and
(UAP) suctioning).
• When delegating to UAP, the registered
• The RN can safely delegate the following nurse (RN) clearly defines the task, time
tasks to the UAP to promote client safety frame for completion, and expected
during toileting and ambulating: outcomes (eg, report client's difficulty
breathing, tolerance of procedures, results
o Place the bedside commode, assistive of vital sign measurements). Furthermore,
devices (eg, canes, walkers), and the RN should be certain that all UAP
personal belongings (eg, eyeglasses, demonstrate competency and have been
hearing aids, cell phones) as close to validated in all delegated tasks.
the client as possible • The RN can safely delegate these tasks to
o Remind the client of the importance of UAP:
changing position slowly to minimize
orthostatic hypotension o Ambulate and promote mobility of
o Report observations of changes in the stable clients
client's condition (eg, level of o Assist with activities of daily living (eg,
consciousness, vital signs, pain level) feeding, bathing, dressing, hygiene)
immediately o Perform oral (nonsterile) suctioning for
o Keep the bed in the lowest position clients during oral care
(locked) as it reduces the distance to the o Collect and document vital signs
floor in the event of a fall o Turn and reposition stable clients
o Provide nonskid footwear for the client
before ambulating • Delegating care to unlicensed assistive
o Keep the environment dry and free of personnel (UAP) requires understanding of
clutter and obstacles (eg, intravenous both body policies and staff member
infusion device tubing and poles, training.
electronic device wires and cords) • UAP may assist with care of stable
clients related to tasks of basic hygiene
• The risk of falling is highest on the night of (eg, bathing, toileting) and daily living (eg,
admission. Clients wake in the middle of feeding, positioning, range-of-motion
 exercises); measurement and • Clients requiring mechanical
documentation of vital signs and intake and ventilation receive care from many
output; and technical skills (eg, capillary members of the health care team. Nurses
blood glucose monitoring, IV catheter must often delegate tasks to ensure that
removal) with appropriate training care is provided in a timely manner. When
• Assurance of appropriateness and delegating, nurses must consider
completion of delegated tasks remain the the stability of the client and the
duty of the nurse. experience level of unlicensed assistive
personnel (UAP). In accordance with
• Many clients with advanced Alzheimer the five rights of delegation, nurses
disease reside in long-term care centers; may delegate the following client care
therefore, most routine care activities can tasks to the UAP:
be delegated to the licensed practical nurse
(LPN) and unlicensed assistive personnel o Performing routine oral care, which will
(UAP). not affect medical stability in a client
• The role of UAP includes: with a tracheostomy tube
o Measuring and obtaining vital signs
o Assisting with activities of daily living o Testing blood glucose (per hospital
(eg, toileting, bathing, skin care, oral policy)
care, personal hygiene) o Performing personal hygiene and skin
o Assisting with feeding care (eg, bathing)
o Reporting changes in ability to eat or o Performing passive and/or active
difficulty swallowing range-of-motion exercises
o Reporting changes in behavior o Measuring output (eg, urinary,
o Placing bed alarms to reduce risk of drainage)
falls
LICENSED PRACTICAL NURSE (LPN)
• The UAP has the skills and knowledge to • Nurses preparing to delegate client care to
perform standard procedures to prevent a licensed practical nurse (LPN) and/or
immobility hazards for a client in traction unlicensed assistive personnel (UAP)
(eg, pneumonia, pressure ulcers, foot drop, should consider the 5 rights of
thromboembolism). When providing care delegation. The LPN can monitor and care
for a stable client, the RN can safely for stable clients who have been initially
delegate these tasks to the UAP: evaluated by a registered nurse
(RN). Interventions LPNs may perform
o Assist with active and passive ROM include:
exercises after the client has been
taught how to perform them by the RN o Administering oral and parenteral
or physical therapist medications, but excluding
o Notify the RN of client reports of pain, administering IV medications, which
tingling, or decreased sensation in the vary by state legislation
affected extremity o Reinforcing teaching and skills that
o Remind the client to use the incentive have been initially taught by the RN
spirometer after the client has been o Focused assessments (eg, bowel
taught proper use by the RN or sounds) after the RN's initial
respiratory therapist assessment
o Maintain proper use of pneumatic
compression devices • The following actions related to ostomy
o Remind the client to move frequently care are generally within the LPN scope of
using the overhead trapeze practice:
 o Provide ostomy care and observe for • Many clients with advanced Alzheimer
skin breakdown disease reside in long-term care centers;
o Perform specific assessments (eg, therefore, most routine care activities can
bowel sounds, stoma color) be delegated to the licensed practical nurse
o Monitor drainage characteristics (eg, (LPN) and unlicensed assistive personnel
color, amount) (UAP).
o Reinforce education • The role of the LPN includes:
o Irrigate an established ostomy
o Document observations and o Administration of enteral feedings (if
interventions prescribed)
o Administration of medications
• The charge nurse should assign the most o Monitoring for safety hazards
stable and predictable client to the LPN. o Monitoring for behavioral changes
• LPNs should not be assigned to clients who
require complex care and clinical judgment DELEGATION
and have potential negative outcomes.
• Licensed practical nurses (LPNs) can
execute higher-level skills under the
direction of a registered nurse (RN).
• These include administering routine
medications for expected needs and
performing focused assessments such as
breath sounds, bowel sounds, and
neurovascular checks (eg, pulse, capillary
refill, numbness).
• LPNs can also monitor findings such as
flow rate and drainage in a client receiving
continuous bladder irrigation
• Wound care and routine medication
administration are the most appropriate
tasks to assign to the LPN. The LPN can
perform sterile procedures and cleanse
and dress wounds for which there is an
established prescription plan

• After performing the initial assessment of

the client post-procedure and comparing it
to the pre-procedure baseline, the
registered nurse (RN) may assign the
following tasks to the licensed practical
nurse (LPN):

o Administer medications
o Monitor neurovascular status of • Delegation is the process of transferring
involved extremity responsibility of performing a task while
o Monitor for bleeding at catheter site maintaining the ultimate responsibility for
every 15 minutes for the first hour, then the action and its outcome.
according to facility policy • The registered nurse (RN) should take into
o Report any changes in neurovascular account the five rights of delegation (right
status or bleeding to the RN task, right person, right circumstances, right
communication/direction, and right
 supervision/evaluation) and the scope of • It is the responsibility of the RN to stay with
practice when deciding which tasks to the client during the first 15 minutes of the
delegate. transfusion, monitor client response, and
• The RN needs to direct the UAP's actions measure vital signs. A transfusion reaction
and communicate clearly about the is most likely to occur during this
assigned tasks including any specific time. However, the RN may delegate
information necessary for completion (eg, measurement of vital signs after the first 15
methods for collection, time frame, when to minutes.
report back to the RN). Option 2 gives the
FLOATING NURSES
UAP directions with prioritization and
specific instructions for reporting back • When asked to "float" to help out in another
findings. unit, the nurse should clarify the duties to
• (Option 1) The time frame in this option be performed.
should be more specific. In addition, there • Many skills/knowledge, such as vital signs
is no communication about what the RN and routine medication administration, are
expects as follow-up. the same in all units.
• (Option 3) The instruction to "keep a close • The nurse should be given a unit
eye" on the client leaves the UAP too much orientation. The nurse should then clarify
room for interpretation. The expectation applicable skills.
from the RN is not clear and the UAP needs • For instance, the nurse could perform basic
more direction. care but not feel comfortable watching the
• (Option 4) The instructions are too broad telemetry cardiac monitors or assisting with
and don't give a specific time frame. This insertion of a pacemaker. These limitations
delegation also needs to communicate the are usually understood and respected.
method needed to accomplish the task. • The qualified and experienced registered
nurses on the unit perform specialized
client needs, and the "float" nurse performs
BLOOD TRANSFUSION basic client needs.
• The registered nurse (RN) is responsible for • The nurse is liable to provide safe care for
the assigned duties and perform them in a
most of the care rendered to a client during
competent manner.
a blood transfusion as this is considered a
high-acuity procedure requiring a high level • The nurse should personally document any
of nursing assessment and judgment. concerns raised with the supervisor and
• Based on the individual state or provincial avoid discussing personal feelings about
the "float" with clients or other staff.
practice act and institutional policy, the RN
may have assistance from a licensed • There is legal precedence that refusal to go
practical nurse with checking blood when asked to "float" can result in
products, verifying client identification, and disciplinary action.
monitoring the blood transfusion rate. • Options in which the nurse can provide safe
• Unlicensed assistive personnel (UAP) care rather make an across-the-board
can obtain the blood product from the refusal should be explored.
blood bank and courier it to the floor where • The hospital is required to provide safe care
the RN will verify the blood product with and is liable if a unit is insufficiently staffed.
another nurse
• UAP can also take vital signs before the
transfusion begins and any time after the
first 15 minutes of infusion
• Only nurses are able to verify blood product
and client identification for blood transfusion
procedures.